Medical Leadership Course

This post is half professional, half confessional. But it concerns the critical limits of professionalism, so let’s call the style apposite.

Over the past year, I’ve been helping to run the medical humanities minor at Rice, out of the HRC. I was also diagnosed with Langerhans histiocytosis, and had a skull tumor removed. It’s commonly observed that academic research is always autobiographical, but in this case it was my life that started to imitate a research agenda!

As a result of this biographical/biological turn, my teaching in this area took on a more practical edge. And when I was asked to teach a course on medical leadership (HURC 306, Spring ’17), I realized that this was an important opportunity to explore how these institutions got to be the way they are (mostly, big and technologically-intensive), and what that has meant for American medicine.

The HRC and the Doerr Institute for New Leaders generously contributed funds to bring in a series of speakers (including Steven Schroeder, the former CEO of the Robert Wood Johnson Foundation, and Ann Robison, the head of the Montrose Center), and to fund undergraduate summer research this year.

In two weeks, my students from 306 will be presenting their final research projects; and so at this transition between phases of our medical leadership project, I’m going to share some remarks I made back in February on the question, at a welcome reception to grant winners hosted by the Doerr Center. Comments/feedback appreciated, as always.

What is “Medical Leadership,” and Why do We Want It

The Urban Institute projects that the congressional bill currently proposed for passage through the budget reconciliation process will eliminate the individual insurance market and gut Medicare and Medicaid, leaving 30 million more people uninsured by 2019, with 82% of these people being in working households (coverage rates will be lower than before the ACA). This is a dangerous situation for the professional identity of all healthcare workers, and those of us who depend on a functioning healthcare system. If medicine comes to be seen a luxury good available only to the relatively well-off or the desperately poor, then doctors cannot assume the survival of their cultural authority, and the relative professional autonomy that comes with it – and at that point, patients won’t really be able to depend on the honest impartiality of their doctors.

It’s at times like these, when we have lost our compass completely, that we end up calling for leaders. That’s the argument with which John Gardner, former Secretary of the Department of Health, Education, and Welfare under Lyndon Johnson, begins his 1990 monograph On Leadership. Of course, he makes his argument in stereotypically liberal fashion, by attacking his central theme. When people cry out for leadership, he says, that’s not exactly what they want:

Why do we not have better leadership? The question is asked over and over. We complain, express our disappointment, often our outrage; but no answer emerges.

When we ask a question countless times and arrive at no answer, it is possible that we are asking the wrong question–or that we have misconceived the terms of the query. Another possibility is that it is not a question at all but simply convenient shorthand to express deep and complex anxieties. It would strike most of our contemporaries as old-fashioned to cry out, “What shall we do to be saved?” And it would be time-consuming to express fully our concerns about the social disintegration, the moral disorientation, and the spinning compass needle of our time. So we cry out for leadership.

Seriously. Those are the first two paragraphs of his book on leadership. Gardner is telling us that when we ask for leaders, it’s usually not because we’ve lost our sense of how to do some important task, but rather that we’ve lost our bearings completely, and have no idea what is important and what is not.

That is essentially what happened in the field of medicine in the 1980’s, when doctors came to realize that the for-profit medical industry that they had helped to build was posing a direct challenge to their professional autonomy. Lots of us experience anomie and directionlessness in late capitalistic society, as Gardner was pointing out; but as the authors of a 1988 paper for the Journal of the American Medical Association point out,

… the physician-organization conflict is different than generic personal-organizational conflict when considering professional autonomy. Organizational intensity threatens physicians’ ability to remain independent.

In other words, institutional life threatens the core of doctors’ professional identities, by forcing them to bring their primary value, the maximization of the patient’s quality of care, into direct contact with a directly contrary value: efficiency. Asking doctors to care less is like asking teachers to teach less; and asking them to do so for the benefit of a corporation’s profits was, at the time, professional anathema.

Our 1988 authors ended their essay by imploring physicians to actively engage with the changing environment:

Medical practice in the future will demand more management-related responsibilities…. [P]hysicians need to adopt a prudent perspective about representation in organizational governance and management issues. This is an immensely important issue for all physicians to resolve personally.

In other words, if you don’t shape corporate medicine to reflect your professional values, your profession will be shaped to reflect the valuation of for-profit corporations.

The topic of leadership therefore ends up being a fascinating pivot on which turn the conflicts of medical professionalism in a hyper-industrialized society. Medicine, like teaching, still retains an aura of a higher calling in a secular society — we can at least say that it allows space to articulate value sets not immediately reducible to profit. And so medicine is not just a useful case study in what happens to professional values in the institutionalization process, but an opening for talking about how we articulate and come to share values at all, in a society made up of large and powerful institutions.

That process, of articulating, debating, and democratically committing to a shared value set, is both possible and necessary for corporate medicine (and nearly all medicine is corporate today). Peter Drucker, the grandfather of management theory, in 1946 articulated corporations as mission-driven (rather than profit-driven) institutions. In quoting this, I am borrowing from Deak Nabers at Brown University.

Any social and political analysis of an institution has to proceed on three levels.

It has to look at the institution as autonomous … capable to be judged in terms of its own purpose.

Every institution has to be analyzed in terms of the beliefs and promises of the society which it serves. …

It has to analyze the institution in its relationship to the functional requirements of the soiety of which the institution is a part….

Values are what hold institutions together. And without a clear value set and a commitment to these values, a profession or even an industry can quickly lose the public’s good favor and be delegitimized.

Dr. Melissa Bailar and I applied for a grant from the Doerr Institute in order to promote student research in this critical area, in part as a supplement to the 300-level Medical Leadership course I am teaching this semester through the new medical humanities minor. In its first stage, the grant allows us to bring medical leaders with a variety of different perspectives to campus, to speak to and run workshops with our medical humanities and broader premed community. These speakers will share their diverse experiences in leadership roles and in studying leaders in the medical field to give students and the community a rich historical context for understanding how individuals and groups have stepped up to shape the medical profession in times of crisis before; how they have found their calling, how they have gathered groups around shared values, and how they have mobilized for change.

Our speaker list includes scholars, executives, and a manager, all of them advocates and leaders for what healthcare is supposed to be and how we can get there, and all of them students, as well, in how we came to be in this situation:

In the project’s second stage, we will competitively fund 3 undergraduate students to work over the summer on their own research projects, learning about medical leadership in present-day Houston institutions and making recommendations for these institutions on the basis of their months-long work.

Our goal, at this critical moment for healthcare (which has been decades in the making), is to empower students and Houston communities to imagine a more just and effective healthcare system that reflects shared values — and this involves opening up the space in which people can have the necessary debates over these values. It is our hope that this course, lecture series, and independent research opportunities will become a fixture in Rice’s medical humanities programming, and in Rice’s connections with local healthcare institutions.